Management of Trauma in a 25-Week Pregnant Woman
A pregnant woman at 25 weeks gestation who has fallen on her abdomen should be admitted for a minimum of 4 hours of cardiotocographic monitoring, even in the absence of abdominal tenderness or vaginal bleeding. 1
Assessment and Initial Management
Initial Evaluation
- Vital signs appear stable (BP 110/80 mm Hg, HR 90 bpm, RR 16 breaths/minute, T 98.4°F)
- No abdominal tenderness or vaginal bleeding noted
- Despite these reassuring findings, trauma during pregnancy carries significant risks
Risks Associated with Trauma in Pregnancy
- Even minor trauma is associated with increased risk of:
- Premature birth (OR 1.20 [1.11-1.31])
- Birth by cesarean section (OR 1.20 [1.13-1.28])
- Fetal distress (OR 1.20 [1.09-1.31]) 1
- More severe trauma carries higher risks of adverse outcomes
Recommended Management
Cardiotocographic Monitoring
- Admission for a minimum of 4-6 hours of cardiotocographic monitoring is recommended 1
- Cardiotocography can detect early signs of fetal distress that may not be apparent on clinical examination
- Admission testing has high specificity for detecting fetal distress already present or likely to develop 2
Monitoring Duration
- In the absence of risk factors or obstetrical events, 4-6 hours of monitoring is sufficient 1
- Risk factors warranting extended monitoring include:
- Gestational age >35 weeks
- Road accidents or assaults
- Sustained contractions
- Abnormal fetal heart rate
- Vaginal bleeding
- Placental abruption
- Abdominal/uterine tenderness
- Maternal tachycardia or hypotension 1
Imaging Considerations
When to Consider Imaging
- CT scan is not routinely indicated for minor trauma with no concerning symptoms 1, 3
- CT should only be performed when the risk/benefit balance clearly favors the diagnostic information needed 1
- Radiation exposure concerns:
- Fetal radiation exposure >50 mGy is associated with doubled risk of childhood cancer
- Exposure >100 mGy may lead to mental retardation
- Exposure >150 mGy increases risk of malformations 3
Alternative Imaging
- Ultrasound is the preferred first-line imaging modality if needed 3
- MRI without gadolinium is safe after the first trimester if additional imaging is required 1
Common Pitfalls to Avoid
- Discharging without monitoring: Even with reassuring initial assessment, fetal distress may develop hours after trauma
- Unnecessary radiation exposure: CT scans should be avoided unless absolutely necessary
- Inadequate duration of monitoring: Minimum 4 hours of cardiotocographic monitoring is essential
- Failure to involve obstetric specialists: Consultation with obstetrics is important for comprehensive care
Follow-up Care
- After monitoring period, if no signs of fetal distress or maternal complications:
- Patient can be discharged with clear instructions
- Arrange prompt obstetric follow-up within 48-72 hours
- Provide warning signs that should prompt immediate return (vaginal bleeding, decreased fetal movement, abdominal pain, contractions)
In conclusion, while the patient's initial presentation appears reassuring, the evidence clearly supports admission for cardiotocographic monitoring to ensure maternal and fetal well-being following abdominal trauma in pregnancy.